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As I mentioned earlier, I’m starting to rev up the studying for the licensing exam. A lot of the studying takes the form of practice questions. They’re actually a lot of fun to do: they force you to think actively about the clinical scenario, keep you on your toes, and make it near-impossible for your eyes to glaze over as you semi-consciously read the same page for the 10th time in a row as your eyelids begin to feel heavy, droop, and you start to….

Yikes! Where was I? Right! The Cavalcade is back! Since I’m sure that most of you don’t believe me when I say that doing practice questions is actually fun, I’m going to use this opportunity to try to convince you. With the aid of sophisticated, peer-reviewed psychometric techniques (or not), I have converted each entry into a USMLE-style “single best answer” multiple choice question. Let’s see how you do!

Cavalcade of Risk: Step 1[49]

Instructions: For each of the following test items, select the one answer that best answers the question posed in the stem.

From Boomer at Boomer&Echo: Which of the following behaviours of financial advisors correlates with the lowest risk of defrauding investors? a) Claiming to have secret/exclusive insider tips that “your broker doesn’t want you to know.” b) Counseling clients that investments with higher expected returns tend to be riskier. c) Offering to move your money offshore to avoid taxation. d) Pressuring you into making a hasty decision on an “exploding offer.” e) Charging abnormally high membership fees.

From Ken Faulkenberry at the AAAMP Blog: If shares of the Notwithstanding Blog Internet Empire (NBIE) earned a 8% return in 2011 and exhibited a beta of +1.2 relative to a benchmark of shares in all medical blogs that collectively earned a 5% return, then: a) The alpha for NBIE in 2011 was +2, making it a good investment. b) The alpha for NBIE in 2011 was +3, making it a good investment. c) The alpha for NBIE in 2011 was -3, making it a bad investment. d) The alpha for NBIE in 2011 was -6.8, making it a bad investment. e) The alpha for NBIE in 2011 cannot be calculated with this information.

From Van R. Mayhall III at the Insurance Regulatory Law Blog: Which of the following statements DOES NOT accurately characterize insurance company insolvency: a) Most state-based insurance guaranty associations are more comparable to private member-based associations than true state agencies. b) Insurance companies are subject to unique state-based insolvency protocols in lieu of entering the federal bankruptcy system. c) Payouts from state insurance guaranty associations are subject to statutory caps. d) Insurance guaranty associations are intended to provide “bailout” financing to prop up faltering insurers. e) None of the above.

From Emily Holbrook at Risk Management Monitor: The shoe-shopping website Zappos.com recently earned positive press for: a) Losing your examiner’s personal information, along with that of millions of other customers. b) Locking out customers from your examiner’s home country for 4 days after a data breach. c) Being named in a potentially-class action lawsuit seeking damages as a result of a data breach. d) Having “some analysts” criticize the company’s response. e) Having “some analysts” praise the company’s response.

From Jason Shafrin, the Healthcare Economist: Medicare’s new value-based purchasing initiative, which aims to reduce payment to “low-quality” doctors, currently uses treatment costs for which of the following chronic diseases as an element of its cost measure (as distinct from its quality measure): a) Hypertension b) Alzheimer’s disease c) Diabetes d) Lung cancer e) Breast cancer

From Louise Norris at Colorado Health Insurance Insider: Colorado’s Medicaid program has recently undergone much change and provoked a great deal of controversy. What happened at the end of 2010 to put Colorado’s Medicaid program on better financial footing? a) Successful negotiations to lower the fee schedule for physicians’ services. b) A 55% increase in enrollment relative to 2007. c) A one-time $13.7 million grant from CMS. d) New dedicated revenue from a sales tax increase. e) The introduction of Medicaid Managed Care programs.

From Dr. Jaan Sidorov, the Disease Management Care Blog: Which of the following is an accurate characterization of Dr. Sidorov’s assessment of Health Insurance Exchanges (HIEs) and recent Kaiser Health News commentary on the subject? a) The left is doing their best to nurture this fledgling institution to maturity in anticipation of the PPACA’s full rollout. b) It’s reasonable for consumers to spend more time shopping for consumer electronics than for health insurance. c) Government-run HIEs will eventually match the ease-of-use and “cool” factor of iPhone apps and online purchasing aids. d) Multiple insurance options on HIEs include variations in provider tiers, out-of-pocket costs, and exclusions. e) Consumer expectations for HIEs will eventually be exceeded.

From Julie Ferguson at Workers Comp Insider: Doctors’ deaths differ from the deaths of other Americans in that: a) Doctors often choose to forgo lifesaving chemo, radiation, and procedures. b) Paradoxically, doctors often do not have access to the full range of lifesaving technologies as the rest of society. c) Non-physicians tend to be more ready to accept death. d) Doctors have a cultural bias against accepting death that isn’t shared by society at large. e) Non-physicians who choose to fight their disease are often pressured by friends and family to be serene in the face of death.

Answer KeyOf course, since you read all the entries, you don’t need one! But just in case: B; A; D; E; C; C; D; A.

Examiner’s Notes

As always, it’s an honour and a pleasure to host the Cavalcade of Risk! If this is your first time at the Notwithstanding Blog, or if you’re coming back after a prolonged absence, I encourage you to take a moment and poke around some of other posts here. From health care policy to health professions training (i.e. medical school), I’ve got it covered.

This was going to be a post about science-based medicine and the law. Really. I still might write it, maybe even tonight. But before I could get started, I cleared my comment spam. Among the usual expected unsavoury entities hawking the usual unsavoury wares, I found two recent spam comments from professionals who really should know better.

I think the law bloggers handle this better than we on the medical side do. There are plenty of social media evangelists in both fields who can be found online treating new technology as an end and not a means, promoting the ideal of “saying anything” over “saying something,” and generally clogging the ‘tubes with tweets, blog posts, and comments that barely even try to masquerade as anythingbeyondmarketing. At least there are some lawyers out there willing to call “shenanigans” when they see them.

I am no luminary in the medical profession. Given that I blog pseudonymously, you can’t even be sure that I am a medical student. I claim no special authority to make pronouncements on medical ethics. I don’t need to. The following statement should speak for itself:

If you are a medical professional, comment-spamming blogs is not an acceptable marketing tactic. If you find yourself keeping company with SEO hucksters and vendors of penis-enlargement pills, you’ve made a wrong turn somewhere.Your online obligations don’t end at HIPAA.

“I will scrub this post of data identifying [you] and [your practice] on two conditions. First condition, [you] must make a sincere apology for [writing spam comments yourself, or] outsourcing [your] reputation and ethics […]. Second condition, [you] must provide emails or other documentation identifying the marketeer [you] hired who produced the comment spam and proving their responsibility for this, so that we can alter the post to call them out by name.”

I was originally going to abandon any effort to post the remainder of my coverage of the American Medical Students Association’s 2011 annual convention when it become clear that it would be so delayed that it could hardly be considered topical. A small number of readers have encouraged me to post the highlight anyways, using the arguments: better late than never; the events left to be blogged were the most interesting; and finally, I may as well “complete the chronicle.”

Many clinicians are resisting the implementation of electronic medical records and other forward-thinking technologies because they dislike change, and technology for that matter. This is likely because the technology that is being imposed on them is difficult to use, or doesn’t feel natural to them.

This is something one hears a great deal of during discussions of physicians and technology. “Physicians are stubborn and resistant to change.” Let’s be honest, who doesn’t know a physician (or 2, or 20) that fits this description?

On its own, this is not a facially illogical explanation for low EMR uptake and resistance to health IT mandates from the government. Of course, many of the prominent organizations who believe that our salvation lies in EMRs and that those pesky, technophobic physicians need to fall into line (think Commonwealth Fund) are the ones who continually remind us that the reason behind the long, inexorable march of increasing health care costs is…

… physicians’ constant readiness and willingness to adopt new technologies and innovations when they feel it will improve patient care, or the bottom line.

Having never seen anyone from these schools of thought even try to explain how these two views are compatible, I can only conclude that some hard doctrinal choices are in order.

***

Argument by Anecdote!

Last week, I was shadowing an older, outpatient physician in a procedure-heavy specialty who is on the voluntary faculty at SUMS, and admits to SUMS’ main teaching site. We talked for a while about the hospital/med school EMR, which we both agree is a nightmarish monstrosity. He was explaining how he was holding off on the paper –> electronic conversion for as long as possible (i.e. until the school forced him), because the product was just so terrible.

He then proceeded to show me the brand-new Siemens ultrasound system that he and his partner had purchased not two weeks ago. He explained the effort that he went through to train himself on it and its new features, and how it was already an improvement over the model he had been using previously. He then proceeded to reminisce about all of the technical wizardry that had been invented in his professional lifetime that he now uses routinely in the office, because he feels that it enhances his ability to care for his patients.

He really, really does not want to switch to the hospital EMR.

Stubborn, resistant to change, and fearful of new technology? You tell me.

Who says medical professionals are scared of new technologies? As of today, you can follow me on Twitter by looking for @NWSblog, or view my 7 most recent tweets on the blog’s sidebar.

What I’m most excited about is the possibility of resurrecting the semi-random links that used to appear in the weekly “Around the Mediverse” feature before I started medical school. Those posts were surprisingly labour-intensive, and it simply wasn’t feasible to continue with them once classes began. My hope is that I can use Twitter to once more share the best of the many, many sources of news/commentary/analysis that I still manage to follow in my spare time.

This is still a very new adjunct to my blogging endeavours, so it might take a while for me to figure out how exactly to make best use of it past this initial trial run. Suggestions are, as always, more than welcome.

Revulsion is not an argument; and some of yesterday’s repugnances are today calmly accepted — though, one must add, not always for the better. […] In crucial cases, however, repugnance is the emotional expression of deep wisdom, beyond reason’s power fully to articulate it.

If I held myself to such high standards, I would tell you that I find the thrust of what I see as mainline bioethical thought to be “icky,” and from thereres ipsa loquitur. However, I’d like to think that my distaste has more than mere “revulsion” behind it, and as such the matter is not so easily disposed of.

In the “standard” ethics and professionalism lectures, medical students are taught that medical ethics rest on three foundational pillars: non-maleficence (“do no harm”); beneficence (“do what’s best for your patient”); and autonomy (“act in accordance with your patient’s wishes”).

Who decides what’s best for the patient, or what constitutes harm? Logically, it should be the patient! When the stakes are high, so too should be the barriers for a physician to substitute his or her goals and values for the patient’s.

SUMS has a thriving medical ethics program, and we’ve had the opportunity to hear clinicians and medical ethicists from SUMS and from farther afield talk about ethical conundrums they’ve seen on the wards. Every presentation has shared one feature, without fail: it’s only an ethical conundrum (usually meriting a call to the bioethics committee) when the physician doesn’t agree with a patient’s choice, and has been unable to successfully use persuasion or coercion to change the patient’s mind.

This seems like a trivial observation at first. After all, why call the ethics committee to adjudicate a matter where the physician and patient are in perfect agreement (aside from rarer edge cases where this happens, usually involving experimental procedures)? It makes perfect sense!

What this means though, is that the medical ethicist has become the person to provide cover for a physician to override the patient’s autonomy. By virtue of selection bias in the cases they are asked to adjudicate, and the ever-present threat of regulatory capture, the role of “medical ethics” runs the risk of devolving into Paternalism 2.0. “We know what’s best for you, and if you don’t believe us, we’ll make you.” What’s more, when the medical ethicist is nothing more than the cudgel with which the physician forces his goals onto his patient, what claim does the ethicist then have to support his monopoly on decision-making in this sphere?

Admittedly, this image of medical ethics is a caricature. But to see the danger that lies in store, look no further than their cousins: the bioethicists.

So why has the medical ethics / bioethics enterprise come to undervalue patient autonomy so extensively? I offer two preliminary hypotheses.

First is the fact that medical ethics and bioethics are situated in an academic-institutional environment that usually leans left-liberal (Progressive). Whether the institution makes the people, or the people make the institution, it comes out to the same thing: the setting is one that inculcates a predilection for top-down technocratic control. I think that this assessment is valid, regardless of what you think of the merits of different political philosophies.

The second one is, in my mind, more interesting. Public choice theory reminds us that bureaucrats, leaders, institutions, and their people do not exist in a world devoid of incentives and personal agendas. As an ethicist, when you say “no,” you entrench the need for your services… there needs to be someone with the authority to say “yes,” and what better way to establish your authority then by saying “no?” When you posit increasingly more complex models for evaluating ethical dilemmas — “autonomy, beneficence, and non-maleficence” just don’t cut it — you create an institutional need for someone with expertise in dealing with these complex rules to act as interpreter, and thereby increase your own power and prestige. Giving full weight to patient autonomy would undermine the need for your services.

This isn’t to say that ethicists make decisions with an explicit eye to entrenching their influence in the medical setting. It is, however, a reminder that we should always be asking ourselves: quis custodiet ipsos custodes? Who watches the watchers?

That, and the “wisdom” of repugnance is only as valid as the reasoning that supports it. Having “a bad feeling” about something doesn’t cut it when lives are on the line.

Like otherenthusiasts of health policy, I spent plenty of time reading and thinking about the Wall Street Journal’s recent reporting on the RUC — the panel that decides how Medicare pays for physicians’ services. The existence of this system was news to many of my classmates, one of whom zeroed in on the hourly wage figures. By MedPAC’s calculation, radiologists would make approximately $193/hr if all of their work was paid at Medicare rates, compared to $101 for primary care physicians and $161 for surgeons.

Why, asked my classmate, should radiologists be paid so much relative to surgeons, given that the training length for diagnostic radiology and surgery is similar, and radiologists arguably play a smaller role in the care of an individual patient, face less malpractice risk (I might quibble with this, but I let it stand), and are able to work “better” hours, doing work that’s less physically demanding?

Now, the WSJ article helps to explain exactly how this situation has come about. The “market” for physicians’ services is one in which nominal and relative prices are set from above. They’ve been set in such a way that the “ROAD to happiness” starts with Radiology. (The “ROAD,” for those unfamiliar with the term, consists of Radiology, Ophthalmology, Anesthesiology, and Dermatology)

This lends itself to an interesting thought experiment. Would diagnostic radiologists fare this well under a market system? I think they would, and here’s why: I think that radiologists are medicine’s superstars, at least in an economic sense.

The reason that major-league athletes and Hollywood A-list celebrities command such high pay is not strictly because we as a society think they are individually more important than, say, an individual teacher or firefighter (or physician). It’s because these athletes and actors are in an industry where the consumer will pay a premium for the “best” (as opposed to minor league teams, indie movies, etc.), and in which many, many consumers can be reached at low marginal cost (cf. television, the internet). The athlete/actor doesn’t have to add a lot of value to a given person, but instead is compensated handsomely because he is able to add some amount of value to a lot of people who are willing to pay for it. Average class size in a public school may be 30, but most sports stadiums can fit tens of thousands, to say nothing of TV and radio audiences.

This strikes me as at least superficially similar to some aspects of diagnostic radiology. The use of medical imaging has exploded in the past 20 years, but it would be bold to claim that none of that increase has to do with the value that it adds to clinical decision-making and patient care (at least when used appropriately). And we as a society have decided that we want the best: that is to say, we want our scans read by radiologists.

What’s more, it’s entirely plausible that a diagnostic radiologist can add her full armamentarium of value to more cases per day than a physician in many other specialties. That it may take less time to read a scan doesn’t lessen the value added by having the scan read. The worth of the information to the patient is independent of the time it takes to derive it (within limits).

So, would radiologists still be on the ROAD in a market-based system of payment? The case in favour looks pretty good. Of course, the challenge facing American radiologists in my lifetime may not be justifying their value in patient care so much as justifying their value over and above their American-boarded Indian-based counterparts. Communications technology has helped make superstars of American radiologists… will it make them overpriced and obsolete as well?